Resilient Ambassadors of Change

Atul Gawande - Moral Hazard 'r Us

You have to check out this piece from the current New Yorker:

Who knew that Health Affairs would be undone by cat cartoons and ads in the back of the magazine for weird shoe sizes?

This is a brilliant piece because it shines a light in so many directions:

• Dr. Gawande and the CT for his kid (wouldn't we all want one more confirmatory scan?)

• The closing sentence re: health care technology prevalence across bum-!*ck America.  What a paragraph!  Them there crappy Texas towns perhaps ain't got no good school buses or any of them new teachers that is trained right or the good new firetrucks with the red and blue sirens, but they got one hell of a collection of magnets over there at the hospitals.

• I was on a call with [a very large health care group purchasing organization] this morning (true story).  I sent them the link last night...told them to look at it before our call.  "Mike, that was an interesting story...what should we take away from the piece?"  The hospital execs sitting there very calmly, very politely--entirely unaware that they were the health care outlier of the Universe.  Beautiful.  That's the story with every hospital in the country.

• Love the part about the stents.  Got chest pain?  Putting in a stent.  Had an extra value meal at Arby's with jumbo fries--let's get the cath cart out.

I'll leave you with this.  Email from my friend John S. (Amber/Bob have spoken with the good doctor) LATE last night:

On Fri, May 29, 2009 at 12:52 AM, John S <john@s.org> wrote:
Well written article, Gawande knows how to tell a story. He briefly references Tulsa in the last paragraph - I can pretty much name the "fellow surgeon" he is talking about. Its not hard, we have a city full of them.

From my perspective as a disgruntled primary care doc living thru a large, academic organization's failing struggles to grapple with economic crisis... I see this as a very good description of the problem(s) with American healthcare. I'd like to think that the quality argument will eventually win over quantity, but quantity pays REALLY well (and we only have hints that quality will be important, maybe, sometime, hopefully soon). The forces of evil don't want anything to change at all and will defend the status quo fiercely.

There is tremendous opportunity here - to provide a method for docs to better understand the impacts of their behaviors (medical decision making for those decision where there isn't much evidence) in a way that they can actually change what they do  - not just to make a buck (or more likely, not lose a buck) but to move the quality needle. From my experience, most docs are not by nature greedy bastards. Some certainly are, and they've seized enough control, or at least influenced the direction of healthcare finance. I think most docs would be overjoyed to work towards improved quality of the care they provide, even if it is cost-neutral.

There are thousands of Grand Junctions out there in need of something to help give them traction. That is where we come in. Imagine this same article 5 years from now and it finds that communities/organizations that used weekly quality data fed back directly to physicians were twice as healthy as those that did not.

But I'm rambling...

-js

Another delicious morsel of patient safety information!

Check out ten medical misconceptions on the Time website. 

CVS Minute Clinic Visit

Two nights ago, I was standing in my kitchen holding my cat, Shadow, pictured to the right.  A noise startled him and he decided to use my palm as a launching pad to catapult himself across the room to hide.

Unfortunately, as my hand is made of FLESH and his back claws are TALONS OF DEATH, I sustained a pretty nasty scratch, pictured below.  I wasn't sure exactly how "bad" the scratch was as far as animal scratches go... it wasn't as bad as if a bear had mauled me, but it was probably the worst cat scratch I've ever had, and as the happy owner of five cats, I've had quite a few.  I decided to just wash it out and slap a band aid over it.  However, when I woke up yesterday morning it wasn't any better.  It was actually stinging more than it was before, and was looking a little swollen.

Man, I don't feel like going to the doctor for this, I thought. Who has time to sit and wait for 50 minutes in the waiting room, and then another 30 in the office?  And that was even IF my doctor could see me today.  I realized that I haven't actually seen a live MD in the office for a long time.  I always see a nurse practitioner, which is just fine by me.  Anyone who can make me feel better is all right with me!  Then I remembered someone mentioning the minute clinic at CVS. 

The Minute Clinic is basically a one-person manned clinic IN CVS.  How much more convenient can you get?!  I found one close to me, as not all CVSs have them, and decided to take a ride over and see how long the wait was to see someone.

The door was closed, so I entered my info into the little touch screen waiting list and saw that I was at the top of the list.  Sweet!  I looked around at brochures and watched the little video provided in the area for what services are provided by the nurse practitioner, the costs for services, etc.  I was pleased to see so much information presented to the patient at once, and in different formats!

The actual visit was like something out of a training video.  The nurse practitioner introduced herself to me and shook my hand.  She asked me all kinds of questions about my cat (was it mine, was it up to date with shots, etc.), about what happened, how I've been treating it myself at home.  All of this before she even did any physical exam of anything!  She was gentle with the exam, and then asked if I minded if she turned her back to me while she typed up the notes.  She actually ASKED me if I minded!  While she was doing her notes, she started asking about medicine allergies, and accessed the CVS pharmacy database to see what other medicines I was on to check for interactions.  She sent the prescriptions right back to the CVS pharmacy (which, I should note, is a separate entity from the Minute Clinic) and asked me if I had any other questions.  Then she printed out all the discharge paperwork - including all the notes she typed up.  I almost laughed out loud thinking of that epsiode of Seinfeld where Elaine tries desperately to get a hold of her chart to see what her doctors are writing in their notes about her.

I don't remember ever feeling so satisfied with an interaction with a medical professional.  I received wonderful care from someone who actually seemed compassionate and interested.  And the icing on the cake?  When I got home and logged into my gmail account I already had emails waiting in my inbox to add the service into my google health account, along with a survey about my visit.  I'm sure you can guess how I rated it.  ;)

I would highly reccommend heading over to the Minute Clinic for anything that isn't too serious.  They accept some insurances, and have pretty good prices for folks who don't.  Check out their site for full details.  This patient was utterly impressed!

President Obama on reducing healthcare costs

A couple of days ago, I decided to follow the White House via Twitter.  Almost hot off the presses I received a text message about a meeting, apparently initiated by major stakeholders of the healthcare industry, with President Obama.   I was immediately directed to the White House's blog--yes the White House has a blog!

In The Briefing Room -- The Blog, you can read the entire post.  There are also links to the original letter from industry to the President, a list of attendees, and a fact sheet that outlines the objectives and goals.  Here's an excerpt from the fact sheet.

HEALTH CARE INDUSTRY LEADERS ARE NOW PLEDGING TO MAKE A MAJOR REDUCTION IN COST GROWTH AS PART OF COMPREHENSIVE HEALTH REFORM: Today, we are seeing the beginning of a change for the future as a wide array of leaders in the health care field – insurance companies, hospitals, pharmaceutical companies, medical device manufacturers, and providers – have come forward with a proposal that could save the country $2 trillion over the next 10 years. They are proposing to take aggressive steps to cut health care costs that, if done in the context of comprehensive health reform, will reduce the annual health care spending growth rate by 1.5 percentage points for the next 10 years.

Here's the press release issued almost immediately after the meeting. 

Oh the benefits of social media! 

e-healthcare may cure many ills

Healthcare costs too much.  Patients are dissatisfied.  Physicians are dissatisfied.  Insurance companies have too much control--patients and doctors too little.  Medical records are scattered.  Too little information is available.  Too much information is available.  The physician workforce is shrinking.  So, what's the good news?  Internet savvy patients, doctors, and other innovative stakeholders are making strides in addressing some of these problems in ways that may become the basis for how healthcare is practiced in the future.

Many clinicians have overestimated the risks of online health resources to their patients and underestimated the benefits.   E-healthcare may be one of the most important cultural medical revolutions of this century, and the majority of physicians are not savvy enough to operate in this emerging culture.   Our future physicians will likely have the benefit of growing up immersed in the internet social and electronic culture, and hopefully with the skills to follow in the footsteps of the pioneers

The e-patient.  More and more, people are seeking healthcare online.  They research their medical problems on a variety of web-based medical sites (e.g., WebMD); they blog and use social networks to share with and learn from others with similar health conditions or interests.   Patients in force are abandoning traditional methods for obtaining medical advice and even treatment plans (i.e., physicians office) in favor of the more on-demand options that the internet offers.  The e-patient has a personal health record.  The e-patient requires a non-traditional approach to healthcare.  The e-patient is extremely active in their own medical care and requires a collaborative relationship with their physicians.  E-patients are blogging and using social networks to share with and learn from others who have similar conditions or interests, and have been for several years.  Our current base of healthcare professionals seem blissfully unaware of the impact that the e-patient might have on the skills they will need to best serve their patients in the near and far future.  The general population seems to be light years ahead in taking advantage of the benefits of the burgeoning social and collaborative electronic culture and tools than our medical professionals.  The net friendliness of clinicians and provider organizations is becoming an important new aspect of healthcare quality. 

The e-doctor.  Unfortunately, the e-doctor is a much more rare species that the e-patient, as the medical community is often slower to adopt changes that the general population readily embrace.  There are some pioneers and early adopters who are empowering and enabling their patients and themselves by embracing trends and adopting technologies to provide a higher quality of patient care and experience.   In addition to encouraging the e-patient as a collaborator and an informed partner in their own healthcare, the e-doctor is a pioneer, often abandoning traditional structures that act as barriers (e.g., insurance reimbursements, traditional office visits, overhead, etc.).  In his practice, the e-doctor is in direct contact with patients, taking advantage of text messaging, email, and social media in order to facilitate treatment and education of their patients.  The e-doctor utilizes cost effective options when running his practice and provides cost effective choices for patients.

Hey I think I've spotted one!  Have a look and listen to Jay Parkinson of Hello Health describe his innovative approach to healthcare. 

Jay Parkinson, Hello Health from Health 2.0 on Vimeo.

What the heck is "rumspringa?"

Driving home from work yesterday, I heard a story on NPR about a psychotherapist who had to change his tactics for treating a large portion of his patient base.  Dr. Jim Cates lives and practices in Topeka, Indiana, where there is a large Amish population.

I’m very familiar with the Amish gig since there is a huge community located in Lancaster, PA which is about an hour drive from Philadelphia.  If you’re not, here’s what Wikipedia has to say about them.  It’s a fascinating culture, based on unwavering religious beliefs and living a simple, honest life.

The program started with Dr. Cates discussing a patient’s family bringing her in to take an IQ test in order to obtain some kind of governmental benefits for her care, as she was mentally disabled.  He realized rather quickly that an IQ test written for mainstream Americans was not going to give him insight into an Amish person’s IQ.  She had no cultural reference for many of the questions asked.   It would almost be like an American taking this Aboriginal Australian IQ test.  He realized then that he had to change his methods if he wanted to treat this population.

The program also talked about the differences he applied to treating Amish teenagers who acquired alcohol or drug dependence during rumspringa.  Truly, cultural competence is becoming more and more important as the lines between cultures blur.

Check out the written article here.

A BarCamp wasn't what I expected, but it still sounds fun

Today I received an email about HealthCamp Philadelphia, which will be held at Thomas Jefferson University on March 28, 2009. It is described as an "unconference" exploring web 2.0 technologies, social media, process innovation and healthcare.  It's totally free, and will be modeled after the "BarCamp" meeting format.  What is a "BarCamp" meeting, you ask?

What a BarCamp is not:

• A 24-hour study group for law students
• A rite of passage for 21-year-olds (in America)
• Anything literally involving tents and beer (most likely)

What a BarCamp is:

• An ad-hoc gathering born from the desire for people to share and learn in an open environment.  It is an intense event with discussions, demos and interaction from participants.
• An event for which all attendees help out (with set-up, designing the agenda, running sessions, etc)
• A meeting of minds where live blogging, bookmarking, emailing, photographing, etc is encouraged
• A self-organized, user-generated, informal, social meeting format

There's no pre-defined agenda at a BarCamp, and in my opinion, that's what makes it different.  I'm excited to attend HealthCamp Philadelphia and experience this meeting format for myself.  I think it could be a really interesting format for interdisciplinary brainstorming on a large scale.  Hopefully I'll get some tips and tricks - perhaps in the future we'll be holding an "Innovative Assessment of Knowledge, Skills, Attitudes and Performance Across the Medical Education:Practice Continuum" barcamp? 

Well, we might want to get a better title.

Disclaimer: This Post Has Not Been Fact-Checked

I was introduced to social media and civic journalism guru Jay Rosen's blog today, and stumbled upon what I felt was a fascinating post summarizing the major points of the journalists vs. bloggers debate.  Of course, the post was written in defense of bloggers, but nevertheless it highlighted some of the key issues, one of which is the tension between "traditional" journalism and blogging. 

Rosen's summary is far better than anything I could write, so I suggest taking at least a cursory scan - but essentially the gist is that journalism holds in high regard its role as an "objective" source of "primary source verified" information, and really, blogging flies in the face of all that.  Blogs are transparent, updated quickly and (hopefully) often, participatory, messy and subjective.  While most serious bloggers certainly avoid mistakes, I believe the value does not emerge from the original post, but from the social processes surrounding it - the open debate, the longitudinal (time) and latitudinal (blogs) tracking of post "topics", the cross-blog engagement, the public empowerment.  What eventually emerges from this process is a picture of the topic - there really is no striving for "100% truth."  This news format threatens journalism as it has been practiced at least the past three decades.  The average citizen now (theoretically) has access to the same information as the journalist, and has the ability to publish anything with (theoretically) the same audience penetration, and it's ok if they make mistakes.  I can just hear the hoardes of journalists now:  "You mean I've been sending my articles through the cubicle gauntlet of fact-checkers all this time, and now anyone can post anything online and it's considered news?  Puh-LEEZ."

Now, for the real question: What effect will this have on innovative assessment across the med ed:practice continuum?

A Veritable Treasure Trove of Links

If you're trying to find a good doctor, or are just interested in looking at how certain places do this kind of thing, check out this article.  Page two lists about a billion¹ links that are informative as all heck.  It warms the cockles of my heart to see so much patient-centered information gathered in one spot.

¹ may be a slight exaggeration

Proton Beam Therapy

This is an article that Steve passed around the other day about the different schools of thought as far as medicine and technology go.  You’ve got people who want their doctors to use cutting edge technology like  (this is actual language from the article) “proton beam therapy” which can vaporize tumors with little damage to surrounding tissue, and you’ve got  people who are happy to just keep things simple with cheaper technologies like x-rays.

Here’s something I never really thought of (or just took for granted) when I read this article:  Toilets are one of the key components to disease control.  SARS was caused by faulty plumbing in a seventh-floor bathroom in Hong Kong.  SARS, people.  That disease that killed all those people, yeah.  Three cheers for sanitation!